An odd cluster of signs and symptoms responded to steroids, but the cause was elusive. A 75-year-old female with a history of hypertension and cerebrovascular accident presented with intermittent lethargy, fevers to 104° F (40° C), dyspnea, and a 1-week history of severe pancytopenia. Her symptoms began 4 months earlier with generalized lethargy and increasing dyspnea, prompting admission at a local hospital. Bilateral pleural effusions and a small pericardial effusion were found, and a thoracentesis identified the effusions as exudative. Cultures and cytology were negative. The patient was discharged on a steroid taper for presumed exacerbation of chronic obstructive pulmonary disease.Over the ensuing months, she was readmitted twice more for recurrent lethargy, fevers, hypotension, and hypoxia of unknown etiology. All admissions were predated by a steroid taper. During each admission, intravenous methylprednisolone sodium succinate resulted in rapid improvement. Shortly after discharge from her third hospital admission, the patient experienced progressive lethargy, altered mental status, and fever to 104° F (40° C).
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— Clare Kelleher, MD, Carrie Herzke, MD
This article originally appeared in December 2011 issue of The American Journal of Medicine.
